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2025 CPT code 11441

Excision of a benign lesion, including margins, from the face, ears, eyelids, nose, lips, or mucous membrane; excised diameter 0.6 to 1.0 cm.

Code selection is based on the excised diameter, which includes the lesion diameter plus the narrowest margin required. Each separately excised benign lesion should be reported individually. More complex closures (intermediate or complex) should be coded separately.

Modifiers may be applicable. For example, if multiple lesions are excised, modifier 59 may be used to indicate a distinct procedural service. Anatomic modifiers should be appended to identify the precise location of the lesion when necessary.

Medical necessity for excision of benign skin lesions must be established based on factors such as symptoms (e.g., pain, bleeding, itching), interference with function, or risk of malignant transformation. Cosmetic reasons are generally not considered medically necessary.

The physician prepares the patient and the surgical area, administers local anesthesia, excises the lesion with appropriate margins, controls bleeding, and closes the wound with a simple, non-layered closure. The excised tissue is usually sent for pathological examination.

In simple words: Removal of a non-cancerous skin lesion from the face, ears, eyelids, nose, lips, or mucous membrane. The area removed includes a small border of healthy skin around the lesion and is stitched closed. The size of the area removed, including the safety margin of healthy skin, is between 0.6 to 1.0 cm.

Excision (including simple closure) of benign lesions of skin (e.g., neoplasm, cicatricial, fibrous, inflammatory, congenital, cystic lesions), includes local anesthesia. Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed. The code selection is based on the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The excised diameter is the same whether the surgical defect is repaired in a linear fashion, or reconstructed (e.g., with a skin graft).

Example 1: A patient presents with a benign cyst on the right cheek, measuring 0.8 cm in diameter. The physician excises the cyst with a narrow margin of healthy skin, and closes the wound., A patient has a 0.7 cm nevus on the left lower eyelid. The physician removes the nevus with a safety margin, ensuring complete excision and minimal scarring., A patient with a 0.9 cm inflamed fibroma on the nose undergoes excision and simple closure of the wound.

Documentation should include the location and size of the lesion, the margins of excision, the method of closure, and any complications encountered. The diagnosis (e.g., cyst, nevus, fibroma) must be documented to support medical necessity. Photographs may also be included.

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